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Oligodendrogliomas are brain tumors with unpredictable biological and clinical behavior. Prognostic factors related to survival are still controversial. The present study reviews 50 patients with well-differentiated (WHO grade II) oligodendrogliomas, located in the cerebral hemispheres and operated upon between 1980 and 1998. Prognostic factors studied include patient's age and sex, tumor location and extent, preoperative KPS, and extent of the surgical resection. The Ki-67 and the proliferative cell nuclear antigen (PCNA) levels were studied in all patients and some growth factors (GFs), including vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), platelet-derived growth factor (PDGF) and tenascine were examined in 20 patients. The long-term outcome and survival are not significantly correlated with the patient's age and sex, tumor location and extent, preoperative KPS and procedure for resection. Patients with lower Ki-67 and PCNA showed a significantly longer survival time (p < 0.001 and p < 0.019, respectively). Between 45 and 70 % of the tumors stained positive for one or more growth factors. Interestingly, cases with late recurrences (more than 4 years after surgery) and longer survival are significantly associated to negative GF expression or slight positivity, as compared with the variable and more often moderate immunoreactivity of cases with early anaplastic recurrences and shorter survival time. The presented data suggest that low proliferation indices and negative GF expression are associated with longer survival in well-differentiated oligodendrogliomas.

The endoscopic endonasal transsphenoidal approach to the sellar region for the removal of pituitary adenomas and of other neoplasms in the same area has proved its reliability and effectiveness for the very wide vision it offers, coupled with minimal surgical trauma. Indications and advantages of such a technique are reported, focused on the treatment of lesions of the sellar and parasellar environment in pediatric age-group patients, and based on a consecutive series of 100 patients, 3 of them adolescents, treated during the last 3 years.

Technique Endoscopic transsphenoidal surgery. New, developing, minimally invasive technique. Removal of pituitary lesions and tumors of the parasellar region. Technical development Endoscopic endonasal transsphenoidal surgery. Endonasal, not transnasal, procedure. Great respect of anatomy. Very wide surgical field, without intraoperative use of a nasal speculum, but with less room in which to work (only one nostril) and potential conflict between the surgeon's hands and the endoscope (both when entering the nostril and while working inside). Instrumentation New instrument. Secure grip. Barycenter of the instrument is the surgeon's hands. Many different tips with different functions. Elimination of the bayonet-like shape. Handle bent in the horizontal plane to avoid interference with the surgeon's hands and to allow the distal, thin part of the instrument to be used safely and comfortably.

A case is reported of successful occlusion of a dural carotid-cavernous fistula (type D) by means of a transvenous anterior approach. Through the left angular vein, the distal superior ophthalmic vein (SOV) and the cavernous sinus were cannulated and three Gianturco coils were delivered close to the fistulous communications. Obliteration of the carotid-cavernous communication was achieved sparing the internal carotid artery and its branches. The major advantage of entering the sinus from the venous route is to preclude any damage to the artery, distal migration of the detachable balloon or of thrombi, intracavernous pseudoaneurysm formation. The trans-orbital approach may be considered chiefly when the openings are in the antero inferior compartment and the SOV is enlarged. Its applications, quite sporadic until now, probably will become more popular, mainly in treating D type fistulas, thanks to the good results achieved and to its safety.

To analyze factors influencing surgical results after microsurgical reconstruction of injured nerves.We report a series of 32 cases of microsurgical nerve reconstruction after traumatizing lesions using nervous autografts. The series comprises 8 reconstructions of radial nerve, 8 of median nerve, 6 of ulnar, and 10 of sciatic nerve. Motor and sensitive deficits have been evaluated preoperatively using a standard grading.A useful sensory recovery has been obtained in radial nerve, as well as in median and ulnar nerve reconstruction. Good results regarding the motor recovery have been obtained in superior limb nerve reconstruction. Sciatic nerve reconstruction showed the worse results.There is a big discrepance between superior limb vs inferior limb results. A more than 10 cm gap has a negative influence on the progression of regenerating axons, especially in median and ulnar nerves.

Percutaneous retrogasserian glycerol rhizolysis (PRGR) became a diffuse and valuable method for treatment of trigeminal neuralgia, following its introduction by Hakanson in 1981. Its main advantages are: a) mild postoperative facial sensory loss, b) simplification of the technique, c) reduction of costs. Our results in a series of 191 patients treated between September 1983 and September 1990 are reported. The procedure was performed according to Hakanson's method with minor modifications. In 11 cases (5.7%) we failed to pierce the foramen ovale; the procedure was successfully repeated a week or two later. In 17 cases it was impossible to obtain CSF from the needle. Complete relief of pain was achieved in 177 patients (92.7%), in 124 (64.9%) immediately, in 53 (27.8%) within 6 days; the operation was unsuccessful in 14 (7.3%). Postoperative sensory evaluation showed: no sensory loss in 33 cases (17.3%); hypalgesia in 8 (4.2%); mild hypesthesia in 88 cases (46.1%), confined to the affected divisions in 45 (23.6%), exceeding it in 43 (22.5%); moderate hypesthesia in 62 cases (32.4%), restricted to the target divisions in 36 (18.8%), exceeding them in 26 (13.6%). No case of anesthesia occurred. Complications of PRGR were: circum-oral ipsilateral herpetic eruption (herpes simplex type), spontaneously and completely regressing: 63 cases (33%); minor dysesthesia, seldom reported as painful: 33 cases (17.3%); impairment of corneal reflex: 19 cases (9.9%), the first branch being the target of the treatment in 11; regressive masticatory weakness; 11 patients (5.7%); aseptic meningitis, promptly regressed: 2 cases (1.0%). Follow-up ranges from 1 to 7 years (Sept. 1983-Sept. 1990). A recurrence was observed in 44 cases (23%): in 15 patients (7.8%) a partial relapse occurred, well controlled by drug therapy and not requiring further surgical treatment; in 29 cases (15.2%) a new percutaneous procedure was required. The mean time of recurrence was 30.5 months. The recurrence rate in the patients of our series at the end of the follow-up period was 23%. Glycerol produces a weak neurolytic lesion, that generates minor post-operative facial deafferentation; it is the best technique, in our opinion, for treatment of tic douloreux.

✓ The fissure separating the motor from the sensory cortex and the substantia gelatinosa capping the posterior horn of the spinal cord are still known by the name of the Italian anatomist Rolando. Luigi Rolando was born in Turin, Italy, in 1773 and died in 1831. His life was not easy, the first of his problems being the death of his father when Rolando was still very young. Three people were to be influential in his life and career: Father Maffei, his maternal uncle who raised him; Dr. Cigna, the anatomy professor who discovered his talent; and Dr. Anformi, a general practitioner who introduced him to the practice of medicine and to the best circles of the city. Forced to leave Turin by the Napoleonic invasion of the country, Rolando first stopped in Florence, where he learned about anatomical dissection, drawing, and engraving and studied the appearance of nervous tissue under the microscope. Later he went to Sardinia where, although cut off from European cultural circles, he developed his major theories. Rolando pioneered the idea that brain functions could be differentiated and located in specific areas and discovered the fixed pattern of cerebral convolutions, highlighting motor and sensory gyri. He demonstrated the complexity of the central gray matter of the spinal cord, describing the “substantia gelatinosa,” and he deduced that nervous structures are connected in a network of nervous fibers linked by electrical impulses. Rolando had to struggle for recognition, however, as the priority of his discoveries was challenged by the almost contemporaneous work of Gall and Spurzheim on cerebral localization and of Flourens on cerebellar function. Nevertheless, his efforts contributed greatly to the clarification of brain function. His observations on nervous anatomy have been especially accurate, as shown by the nomenclature “fissure of Rolando” and “substantia gelatinosa of Rolando.”

Trans-sphenoidal surgery has a very low rate of complications despite a series of apparently negative anatomo-topographical factors. Complications may be either mechanical or functional, transitory or permanent. The most important complications are: hematoma of the focus, sub-arachnoid hemorrhage, empty sella, liquoral fistula, opto-chiasmatic lesions, arterial lesions, lesions of the cavernous sinus, parenchymal damage, nasal and paranasal mechanical lesions, insipid diabetes, hypopituitarism. The overall mortality rate is 0.4-1% and is always associated with predisposing factors, such as previous treatment, voluminous extrasellar growth, concomitant causes of disease; the most frequent causes of death are: hemorrhagic phenomena in the extrasellar portion of large size adenomas; vascular lesions involving the intracavernous carotid artery; and hypothalamic lesions. The frequency of major complications is in the region of 2.3%. Predisposing factors are: volume, consistency, invasiveness, previous treatment, intratumoral necrotic-hemorrhagic phenomena, age. Surgery is only indicated for some of the above complications, including hematoma of the focus, acute postoperative empty sella, rhinoliquorrhea resistent to conservative treatment, excessive filling of the sellar cavity. All the other possible complications are results or functional alterations which must be treated medically, even if a specific therapy only exists for some (such as early hypotonic polyuria). The series of patients reported here refers to the period 1978-1989 and accounts for a total of 259 trans-sphenoidal operations performed in 245 patients. Of the secondary operations, 6 were due to postoperative complications (hematoma of the focus in 2 cases, rhinoliquorrhea in 2 cases; empty sella and hemorrhagic infarction of a large suprasellar site in the 2 remaining cases). There were 2 deaths related to direct mechanical complications (both caused by hemorrhagic infarction of large tumoural residues and the surrounding cerebral parenchyma). Complications which did not require re-operating were observed in 11 further cases: 6 cases of persistent rhinoliquorrhea which required protracted spinal drainage; 2 cases of deterioration of previous visual deficits unrelated to either hematoma of the focus or empty sella but caused by trauma to optic structures, either directly or on a vascular basis; 3 cases of dyplopia due to oculomotory deficiency. In terms of hypophyseal function, the ex-novo onset of postoperative pan-hypopituitarism and insipid diabetes was only observed in one case.(ABSTRACT TRUNCATED AT 400 WORDS)

A ten-year experience on 36 patients bearing macroprolactinomas (MP) and 86 others bearing microprolactinomas (mP) is reported in this study. Different therapeutical approaches were used: 1) trans-sphenoidal surgery in 24 patients with MP and in 25 with mP; 2) medical therapy with the oral form of bromocriptine (BRC) in all the 24 patients with MP previously subjected to surgery, in 48 patients with mP ab initio, and in 16 out of 25 patients with mP previously subjected to surgery; 3) medical therapy with the long-acting injectable forms of BRC in 12 MP- and 13 mP-bearing patients, and 4) conventional radiotherapy in 12 of the 24 patients with MP previously subjected to surgery. The follow-up, performed five years after surgery, showed that: a) all the 24 patients with MP but one had normal PRL levels during BRC administration, with a rebound of hyperprolactinemia in all cases after withdrawal; b) during the treatment BRC caused normalization of PRL in 15 of the 16 mP-bearing patients surgically treated and in all the 48 mP-bearing patients only treated with BRC; c) in 20 of the 25 patients the treatment with injectable retard BRC caused the normalization of plasma PRL and the shrinkage of the tumor mass in all the patients with MP but one, as revealed by seriate CT scans. In conclusion, the surgical treatment of prolactinomas was ineffective to normalize plasma PRL levels in most patients whereas BRC, in standard or in retard forms, was able to normalize plasma PRL levels, reduce the tumoral mass and preserve the pituitary residual tissue. BRC should be, therefore, used as first choice therapy both for MP and mP.